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EmergencyWar Surgery

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Previous page:Hero’s Highway shuts down. Airmen from the 332nd Expeditionary Medical Group carry a stretcher under the Hero’s Highway flag during an aeromedi-cal evacuation training exercise. The historical flag was recently cased in a ceremony on September 1, 2011. Photograph: US Air Force photo no. 110707-F-GU448-007.Photographer: Senior Airman Jeffrey Schultze.

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EmergencyWar Surgery

Fourth United States Revision

2013

Borden InstituteUS Army Medical Department Center and School

Fort Sam Houston, Texas

Office of The Surgeon GeneralUnited States Army

Falls Church, Virginia

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“All the circumstances of war surgery thus do violence to civilian concepts of traumatic surgery. The equality of organizational and professional management is the first basic difference. The second is the time lag introduced by the military necessity of evacuation. The third is the necessity for constant movement of the wounded man, and the fourth—treatment by a number of different surgeons at different places instead of by a single surgeon in one place—is inherent in the third. These are all undesirable factors, and on the surface they seem to militate against good surgical care. Indeed, when the overall circumstances of warfare are added to them, they appear to make more ideal surgical treatment impossible. Yet this was not true in the war we have just finished fighting, nor need it ever be true. Short cuts and measures of expediency are frequently necessary in military surgery, but compromises with surgical adequacy are not.”

—Michael E. DeBakey, MD Presented at Massachusetts General Hospital

Boston, October 1946

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THE FOURTH UNITED STATES REVISION

of

EMERGENCY WAR SURGERY

IS DEDICATED TO THE

COMBAT PHYSICIAN

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Emergency War Surgery

Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages cited herein. However, it is the responsibility of every practitioner to consult appropriate information sources to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs and procedures. The authors, editors, publisher, and the Department of Defense cannot be held responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does not imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men.

The opinions or assertions contained herein are the personal views of the authors and are not to be construed as doctrine of the Department of the Army or the Department of Defense. For comments or suggestions on additional contents in forthcoming editions, please contact the publisher (www.cs.amedd.army.mil/borden).

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS. ALL RIGHTS RESERVED.

NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER OR COPYRIGHT OWNER.

Published by the Office of The Surgeon GeneralBorden InstituteFort Sam Houston, Texas 78234-6100

Library of Congress Cataloging-in-Publication Data

Emergency war surgery (Borden Institute) Emergency war surgery. -- Fourth United States revision. p. ; cm. Includes bibliographical references and index. I. Borden Institute (U.S.), editor of compilation. II. Title. [DNLM: 1. Emergencies--Handbooks. 2. Wounds andInjuries--surgery--Handbooks. 3. Military Medicine--Handbooks. WO 39] RD151 617.9’9--dc23 2013031557

PRINTED IN THE UNITED STATES OF AMERICA19, 18, 17, 16, 15, 14, 13 5 4 3 2 1

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Contents

Editorial Board xiContributors xiiAcknowledgments xviiForeword xixPreface xxiPrologue xxiii

Chapter 1: Weapons Effects and War Wounds 1

Chapter 2: Roles of Medical Care (United States) 17

Chapter 3: Mass Casualty and Triage 29

Chapter 4: Aeromedical Evacuation 47

Chapter 5: Airway/Breathing 61

Chapter 6: Hemorrhage Control 69

Chapter 7: Shock, Resuscitation, and Vascular Access 77

Chapter 8: Anesthesia 89

Chapter 9: Soft-Tissue and Open Joint Injuries 101

Chapter 10: Infections 113

Chapter 11: Critical Care 131

Chapter 12: Damage Control Surgery 175

Chapter 13: Face and Neck Injuries 183

Chapter 14: Ocular Injuries 205

Chapter 15: Head Injuries 219

Chapter 16: Thoracic Injuries 241

Chapter 17: Abdominal Injuries 257

Chapter 18: Genitourinary Tract Injuries 277

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Chapter 19: Gynecological Trauma and Emergencies 291

Chapter 20: Wounds and Injuries of the Spinal Column and Cord 307

Chapter 21: Pelvic Injuries 317

Chapter 22: Extremity Fractures 327

Chapter 23: Amputations 341

Chapter 24: Injuries to the Hands and Feet 349

Chapter 25: Vascular Injuries 357

Chapter 26: Burns 377

Chapter 27: Environmental Injuries 393

Chapter 28: Radiological Injuries 427

Chapter 29: Biological Warfare Agents 435

Chapter 30: Chemical Injuries 443

Chapter 31: Pediatric Care 451

Chapter 32: Care of Enemy Prisoners of War/Internees 461

Chapter 33: Battlefield Transfusions 467

Chapter 34: Compartment Syndrome 489

Chapter 35: Battlefield Trauma Systems 497

Chapter 36: Emergency Whole Blood Collection 503

Envoi 513

Appendix 1: Principles of Medical Ethics 515

Appendix 2: Glasgow Coma Scale 519

Appendix 3: Department of Defense Trauma Registry 521

Abbreviations and Acronyms 529

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Significant Military Medical Terms 541

Product Manufacturers 543

Index 545

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Editorial Board

Chair/Senior Medical EditorMiguel A. Cubano, MD, FACS

CAPT, MC, US NavyDeputy Commander

Defense Medical Readiness Training InstituteFort Sam Houston, Texas

Executive Medical EditorMartha K. Lenhart, MD, PhD, FAAOS

COL, MC, US Army

Medical Co-Editors Jeffrey A. Bailey, COL, MC, US Air Force

George P. Costanzo, COL, MC, US Air ForceBrian J. Eastridge, COL, MC, US Army

James R. Ficke, COL, MC, US ArmyChristopher M. Hults, CDR, MC, US NavyZsolt T. Stockinger, CAPT, MC, US Navy

Borden Institute Editorial StaffDaniel E. Banks, MD, MS, MACP

LTC, MC, US ArmyDirector and Editor in Chief

Timothy K. Jones, DDSCOL (Ret), DC, US Army

Assistant Director

Vivian Mason Douglas Wise Volume Editor Layout Editor

Bruce MastonIllustrator

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Contributors

Romney Anderson, COL, MC, US ArmyJayson Aydelotte, MAJ, MC, US ArmyMartin Baechler, COL, MC, US ArmyJeffrey A. Bailey, COL, MC, US Air ForceLinda Beltra, CAPT, MC, US NavyJohn R. Benjamin, CDR, MC, US NavyTerence G. Benson, MAJ, BSC, US Air ForceAlan Berg, COL, MC, US Air ForceJohn Bini, LT COL, MC, US Air ForceIan H. Black, MAJ, MC, US Army ReservesSharon Blondeau, CAPT, NC, US NavyHarold R. Bohman, CAPT (Ret), MC, US NavyMark E. Boston, COL, MC, US Air ForceMark W. Bowyer, COL (Ret), MC, US Air ForceJoseph Brennan, COL, MC, US Air ForceChester Buckenmaier III, COL, MC, US ArmyFrank Butler, CAPT, MC, US ArmyJeremy W. Cannon, LT COL, MC, US Air ForceRamon F. Cestero, CDR, MC, US NavyMichael Charlton, LT COL, MC, US Air ForceGeorge P. Costanzo, COL, MC, US Air ForceTracy Cotner-Pouncy, RNJames E. Cox, COL (Ret), MC, US Air ForceMiguel A. Cubano, CAPT, MC, US NavyVirgil Deal, COL, MC, US ArmySherrilee A. Demmer, RN, BSNWarren Dorlac, COL, MC, US Air ForceDavid Dromsky, CDR, MC, US NavyJames Dunne, CAPT, MC, US NavyBrian J. Eastridge, COL, MC, US ArmyMary Edwards, LTC, MC, US ArmyJames R. Ficke, COL, MC, US ArmyStephen Flaherty, COL, MC, US ArmyRichard Gonzales, COL, MSC, US ArmyKurt Grathwohl, COL, MC, US ArmySteven Hadley, COL, MC, US Air Force

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Contributors

Dan R. Hansen, COL, MC, US ArmyKenneth C. Harris, COL, MC, US ArmyScott Helmers, CAPT, MC, US NavyLinda Hill, LCDR (Ret), MSC, US NavyChristopher M. Hults, CDR, MC, US NavyJoel Jenne, LT COL, MC, US Air ForceJefferson Jex, MAJ, MC, US ArmyJason Johnson, MAJ, MC, US ArmyTimothy K. Jones, COL (Ret), DC, US ArmyWarren Kadrmas, LT COL, MC, US Air ForceJohn Keeling, CDR, MC, US NavyJames Keeney, LT COL, MC, US Air ForceJess Kirby, MAJ, MC, US ArmyKevin Kirk, LTC, MC, US ArmyEric Kuncir, CAPT, MC, US NavyJulio Lairet, MAJ, MC, US Air ForceRonald A. Lehman, LTC, MC, US ArmyMartha K. Lenhart, COL, MC, US ArmyHenry Lin, CDR, MC, US NavyMark A. MacDougall, LTC, AN, US ArmyPatricia McKay, CAPT, MC, US NavyAlan Murdock, LT COL, MC, US Air ForceDavid Norton, LT COL, MC, US Air ForceShawn Passons, LCDR, NC, US NavyJeremy Perkins, LTC, MC, US ArmyBenjamin Potter, MAJ, MC, US ArmyJoseph Rappold, CAPT, MC, US NavyTodd Rasmussen, LT COL, MC, US Air ForceFrancisco Rentas, COL, MC, US ArmyEvan Renz, COL, MC, US ArmyMark Richardson, COL, MC, US Air ForceKeyan Riley, MAJ, MC, US Air ForceJohn R. Rotruck, CDR, MC, US NavyZsolt T. Stockinger, CAPT, MC, US NavyJoseph Strauss, CDR, MC, US NavyDaniel Unger, CAPT, MC, US NavyTeun van Egmond, COL, MC, Royal Netherlands ArmyGlenn Wortmann, COL (Ret), MC, US Army

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Illustration ContributorsE. WeissbialJoint Trauma SystemSonoSite, Inc

IllustratorsBruce MastonJessica ShullDouglas Wise

2004 Contributors

We also pay tribute to the contributors of the 2004 Edition of Emergency War Surgery:

Editors Ronald F. Bellamy, COL (Ret), MC, US Army Matthew Brengman, MAJ, MC, US ArmyDavid G. Burris, COL, MC, US ArmyPaul J. Dougherty, LTC, MC, US ArmyDavid C. Elliot, COL, MC, US ArmyJoseph B. FitzHarris, COL, MC, US ArmyStephen P. Hetz, COL, MC, US ArmyJohn B. Holcomb, COL, MC, US ArmyDonald H. Jenkins, LTC, MC, US Air ForceChristoph Kaufmann, LTC, MC, US ArmyDave Ed. Lounsbury, COL, MC, US ArmyPeter Muskat, COL, MC, US Air ForceLawrence H. Roberts, CAPT, MC, US Navy

ContributorsKeith Albertson, COL, MC, US ArmyRocco A. Armonda, LTC, MC, US ArmyKenneth S. Azarow, LTC, MC, US ArmyRonald F. Bellamy, COL (Ret), MC, US Army Gary Benedetti, LTC, MC, FS, US Air ForceWilliam Beninati, LTC, MC, US Air ForceMatthew Brengman, MAJ, MC, US ArmyDavid G. Burris, COL, MC, US ArmyFrank Butler, CAPT, US NavyMark D. Calkins, MAJ, MC, US ArmyLeopoldo C. Cancio, LTC, MC, US ArmyDavid B. Carmacke, MAJ, MC, FS, US Air ForceMaren Chan, CPT, US Army

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David J. Cohen, COL, MC, US ArmyJan A. Combs, MAJ, MC, US ArmyPaul R. Cordts, COL, MC, US ArmyNicholas J. Cusolito, MAJ, NC, US Air ForceDaniel J. Donovan, LTC, MC, US ArmyPaul J. Dougherty, LTC, MC, US ArmyDavid C. Elliot, COL, MC, US ArmyMartin L. Fackler, COL (Ret), MC, US Army John J. Faillace, MAJ, MC, US ArmyGerald L. Farber, LTC, MC, US ArmyJoseph B. FitzHarris, COL, MC, US ArmyStephen F. Flaherty, LTC, MC, US ArmyRoman A. Hayda, LTC, MC, US ArmyJohn B. Holcomb, COL, MC, US ArmyMichael R. Holtel, CAPT, MC, US NavyStephen P. Hetz, COL, MC, US ArmyJeffrey Hrutkay, COL, MC, US ArmyAnnesley Jaffin, COL, MC, US ArmyDonald H. Jenkins, LTC, MC, US Air ForceJames Jezior, LTC, MC, US ArmyChristoph Kaufmann, LTC, MC, US ArmyKimberly L. Kesling, LTC, MC, US ArmyThomas E. Knuth, COL, MC, US ArmyWilma I. Larsen, LTC, MC, US ArmyGeorge S. Lavenson, Jr, COL (Ret), MC, US Army James J. Leech, COL, MC, US ArmyDave Ed. Lounsbury, COL, MC, US ArmyChristian Macedonia, LTC, MC, US ArmyCraig Manifold, MAJ, MC, US Air ForcePatrick Melder, MAJ, MC, US ArmyAlan L. Moloff, COL, MC, US ArmyAllen F. Morey, LTC, MC, US ArmyDeborah Mueller, MAJ, MC, US Air ForcePeter Muskat, COL, MC, US Air ForceMary F. Parker, LTC, MC, US ArmyGeorge Peoples, LTC, MC, US ArmyKaren M. Phillips, LTC, DC, US ArmyRonald J. Place, LTC, MC, US ArmyPaul Reynolds, COL, MC, US ArmyLawrence H. Roberts, CAPT, MC, US NavyDavid Salas, Msgt (Ret), US Air Force Joseph C. Sniezek, MAJ, MC, US ArmyScott R. Steele, CPT, MC, US ArmyAllen B. Thach, COL, MC, US Army ReserveJohnny S. Tilman, COL, MC, US ArmyJohn M. Uhorchak, COL, MC, US ArmySteven Venticinque, MAJ, MC, US Air ForceIan Wedmore, LTC, MC, US Army

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Additional Contributors Chester Buckenmaier, LTC, MC, US ArmyEskil Dalerius, COL, Swedish Armed ForcesMichael Deaton, COL, MC, US ArmyWilliam Dickerson, COL, US Air Force Peter Rhee, LTC, MC, US ArmyGlenn Wortmann, LTC, MC, US Army

IllustratorsBruce MastonJessica Shull

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Acknowledgments

Special acknowledgment to CAPT W. R. Dalton, Commander of the Defense Medical Readiness Training Institute, for his leadership and oversight during this revision of Emergency War Surgery.

The information contained in this book reflects a generous col-laborative effort. Thank you to all of the contributors and content reviewers for their valuable time and contributions.

Thanks to Donalda (Dee) Smith whose efforts and selfless service were unprecedented. Dee deserves special recognition for persever-ing and committing more than 3 years to getting this book organized, connecting doctors with chapters, and providing untiring service to see it to its completion. She was the driving force behind this book and spent countless hours making phone calls, sending multitudi-nous e-mails, and communicating with doctors all over the country and OCONUS. Without her, this book would not have been possible.

Tremendous gratitude to Colonel Martha Lenhart of the Borden Institute who was instrumental in ensuring that this book was a priority, and who selflessly provided guidance and encouragement during all stages of its production. We would also like to express our sincere thanks to Vivian Mason, Volume Editor, Borden Institute, for her dedication and technical support.

Special recognition to the following individuals for putting forth that extra effort: Harold R. Bohman, CAPT (Ret), MC, US Navy; Mark W. Bowyer, COL (Ret), MC, US Air Force; Ramon F. Cestero, CDR, MC, US Navy; Warren Dorlac, COL, MC, US Air Force; Mary Edwards, LTC, MC, US Army; Stephen Flaherty, COL, MC, US Army; Dan R. Hansen, COL, MC, US Air Force; Kenneth C. Harris, COL, MC, US Army; Linda Hill, LCDR (Ret), MSC, US Navy; Jason Johnson, MAJ, MC, US Army; Henry Lin, CDR, MC, US Navy; Mark A. MacDougall, LTC, AN, US Army; Alan Murdock, LT COL, MC, US Air Force; Joseph Rappold, CAPT, MC, US Navy; and Evan Renz, COL, MC, US Army.

Miguel A. Cubano, MD, FACSCaptain, MC, US Navy

Deputy CommanderDefense Medical Readiness Training Institute

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Foreword

It is an honor for me to acknowledge the time, efforts, and experience collected in this fourth revision of Emergency War Surgery. Once again, a team of volunteers representing the Military Health System and numerous clinical specialties has committed itself to compiling state-of-the-art principles and practices of forward trauma surgery.

War surgery and treatment of combat casualties at far-forward locations, frequently under austere conditions, continue to save lives. Military medical personnel provide outstanding health support to those who serve in harm’s way. As war has evolved, so has our medical support to those who fight. Today, American service members face a new terrain of mobile urban conflict. Despite advances in personal and force protection, our forces remain vulnerable to blast wounds, burns, and multiple penetrating injuries not usually encountered in civilian settings. This publication expertly addresses the appropriate medical management of these and other battle and nonbattle injuries.

I congratulate contributors to this edition for drawing on the experiences of colleagues who recently returned from tours of duty in Southwest Asia to provide the most current handbook. I wish to publicly extend my gratitude, and that of the American people, to the courageous men and women who serve in the medical departments of our armed services. I commend your dedicated service and acknowledge your sacrifices, and those of your families, to provide the best healthcare to those who protect our nation. All Americans are indebted to your service.

Jonathan Woodson, MDAssistant Secretary of Defense for Health Affairs

Director of TRICARE Management Activity

May 2012Washington, DC

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Preface

The moral test of a nation’s character is how its citizens care for those who are ill or injured as a consequence of war. This edition of the Emergency War Surgery manual (the 4th revision) exemplifies the continuing commitment of military healthcare providers to Soldier well-being across the continuum of care from remote battlefields to stateside evacuation. This resource epitomizes shared knowledge from healthcare providers dedicated to the delivery of lifesaving care, which underpins our honored legacy of military medicine. The authors have documented our providers’ intellectual commitment and unwavering ability to advance the practice of medicine under arduous combat conditions. The battlefield experience has always informed medicine. The increased experience of combat and innovation resulting from the last decade of war will forever be etched within the pages of this manual, not as a monument for posterity, but as a practical handbook to enhance the working medical knowledge and skills of our fighting force.

It is said that the Greek god of medicine, Asclepius, was born as a result of an emergency medical intervention. Heroic acts of courage by Soldiers, Sailors, Airmen, and Marines are a testament to our nation’s ability to overcome adversity even in the face of mortal challenge. As enemy tactics in Iraq and Afghanistan evolved, with increased application of improvised and vehicle-borne explosive devices, medical leaders at all levels questioned existing paradigms and conventional wisdom. They developed evidence-based Clinical Practice Guidelines, changed or augmented existing treatment modalities, and spearheaded progressive alterations to ballistic survival gear. From the application of tourniquets at the point of injury to the design and development of prosthetics during the rehabilitative phase of treatment, our medical teams continue to conduct new research and challenge medical dogma to solve current problems.

Emergency War Surgery is a testament to the courage exhibited by our military men and women in these difficult times. This manual represents the collective efforts of numerous military scholars and

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pays homage to those who willingly paid the ultimate price of freedom. Each word should be read in their honor.

With honor, humility, and profound admiration, we present the 4th edition of the Emergency War Surgery manual with the express hope that we will not forget the lessons we have learned.

Patricia D. HorohoLieutenant General, US Army

Surgeon GeneralCommanding General US Army Medical Command

Matthew L. NathanVice Admiral, US Navy

Surgeon General

Thomas W. TravisLieutenant General, US Air Force

Surgeon General

April 2013Washington, DC

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Prologue

“War is the only proper school for the surgeon.” — Hippocrates

Within the last century, our wars have traveled from the hedgerows of Europe and beaches in the Pacific, to the jungles of Vietnam, and now to the deserts and mountains of Southwest Asia. The common denominator of these conflicts is intense human suffering and death as a result of injury on the battlefield. Most recently, after a decade of war, what is recent past is prologue for this work: more than 5,000 dead and tens of thousands of combat casualties with significant injury in the decade from 2001 to 2011. Per the philosophy of Hippocrates, “What have we learned?” and, more importantly, how can we pass that knowledge along to those who will follow? As the concept of modern warfare has changed, so, too, has medical care evolved on the battlefield. The current contingency operations have produced medical advances that will be our legacy and the new foundations for the military surgeons of the future.

War surgery today is about using evidence and best practice to optimize care of our wounded warriors. Although grounded in the fundamental training of the general surgeon and surgical specialist, it must be adaptive to the challenges of extremely high injury acuity, the burden of overwhelming casualty numbers, long and unforgiving hours, environmental extremes, logistical austerity, and the reality that mission accomplishment may precede medical necessity. It is a concept built on realistic experience and lessons learned over a decade of continuous conflict. War has predictably proliferated innovations in medicine and surgery. Modern technology and communication have yielded substantial impact on the battlefield, in that we are better able to use contemporary lessons learned to disseminate, educate, and change practice to mitigate casualty outcomes in relatively “real time.”

Advances in combat casualty care are associated with the lowest case fatality rate in the history of warfare, a fact rendered even more remarkable by the complexity of injury and expedited

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transcontinental evacuation of casualties across the globe. Within this realm of medical innovation, one of the most important contemporary advances to military medicine on the battlefield has been the development and implementation of the Joint Trauma System, a system whose singular vision is that every soldier, Marine, sailor, or airman injured on the battlefield or in the theater of operations has the optimal chance for survival and maximal potential for functional recovery. The motto of the system is “Right Patient, Right Time, Right Place, Right Care.” The trauma system is built on the infrastructure of the Department of Defense Trauma Registry (DoDTR), in that data improve medical care; that data drive doctrine, policy, and decision-making; and that data create new knowledge to further the evolution of battlefield care. Pertinent to the casualty and the surgeon, the mission of the Joint Trauma System is to improve trauma care delivery and patient outcomes across the continuum of care, utilizing continuous performance improvement and evidence-based medicine. Value of the trauma system is evidenced by development of more than 36 evidence-based battlefield relevant Clinical Practice Guidelines (CPGs) that have decreased morbidity and mortality from combat injury. Relevant CPGs are cited extensively in this version of Emergency War Surgery.

Furthermore, the antiquated system of prehospital care espoused by Pre-Hospital Trauma Life Support (PHTLS) has been ubiquitously supplanted by the paradigm of Tactical Combat Casualty Care (TCCC), divided into phases depending on the tactical scenario. In each phase, the greatest potential threat to life is managed as a priority in the context of mission capability and mission completion. Embedded within the overarching concept of TCCC are hemorrhage control and airway management. Tourniquet utilization has become a fundamental pillar of hemostasis in TCCC and has been shown to be associated with an attributable survival advantage.

Developers of the technique of balanced resuscitation coined the term “damage control resuscitation.” It was conceptualized on this battlefield and has reduced the mortality rate of massive transfusion casualties from 40% to less than 20%. Further refinements of this resuscitation paradigm include the use of

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novel hemostatic agents, coagulopathy testing modalities, and even mobile resuscitative team strategies.

Even with all of the advances that have taken place on the battlefield in the last decade, several challenges loom on the horizon. Despite the lowest case fatality rate in history, the “died of wounds rate” remains largely unchanged. The vast majority of combat casualties die on the battlefield before ever reaching a medical treatment facility. Therefore, the greatest chance to impact combat casualty care occurs long before the surgeon ever has the opportunity to stop the bleeding. The charge to the generation of surgeons reading this text is to make this situation better.

It is the earnest hope of the authors of this Emergency War Surgery handbook that it will gather dust on the shelves of tomorrow’s military surgeon, knowing all too well that with predictable certainty that far too soon the “balloon will go up” and military surgeons will once again heed the call.

There is no greater calling, nor greater responsibility, nor greater sense of worth than to care for a wounded brother-in-arms.

Brian J. Eastridge, MD, FACSColonel, MC, US Army

Trauma Consultant, US Army Surgeon General

Miguel A. Cubano, MD, FACSCaptain, MC, US Navy

Deputy CommanderDefense Medical Readiness Training Institute

Jeffrey A. Bailey, MD, FACSColonel, MC, FS, US Air ForceDirector, Joint Trauma System

May 2012San Antonio, Texas

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